Surgical Science, 2014, 5, 363-367 Published Online August 2014 in SciRes. http://www.scirp.org/journal/ss http://dx.doi.org/10.4236/ss.2014.58059

How to cite this paper: Traoré, A., et al. (2014) Post-Operative Peritonitis: Diagnostic Problems, Morbidity and Mortality in Developing Countries. Surgical Science, 5, 363-367. http://dx.doi.org/10.4236/ss.2014.58059

Post-Operative Peritonitis: Diagnostic Problems, Morbidity and Mortality in Developing Countries Alhassane Traoré1,2*, Bakary Tientigui Dembélé1,2, Adégné Togo1,2, Lassana Kanté1,2, Madiassa Konaté1,2, Ibrahima Diakité2, Simo Notue Fabienne Laurence2, Boubacar Karembé2, Abdoulaye Diarra2, Amadou Traoré2, Mahamane Djibo Diango1,3, Gangaly Diallo1,2 1Faculty of Medicine and Odonto-Stomatology, Bamako, Mali 2Department of General Surgery, CHU Gabriel Touré, Bamako, Mali 3Department of Anesthesia and Intensive Care, CHU Gabriel Touré, Bamako, Mali Email: *Alhassanetraore2008@yahoo.fr Received 25 May 2014; revised 24 June 2014; accepted 22 July 2014

Copyright © 2014 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

Abstract Goal: To study the diagnostic difficulties and post-operative morbidity and mortality of peritonitis. Patients and Methods: Retrospective study about the records of adult patients operated on be-tween 1999 and 2013 whose diagnosis of post-operative peritonitis was made. Results: We achieved 23,573 lanterns and recorded 148 cases of postoperative peritonitis or 0.62%. The medium age was 37.1 ± 17.7 years and the sex ratio was 1.2. The delay between the initial intervention and reoperation was less than 5 days. Factors occurrence of postoperative peritonitis were those re-lated to the initial surgery: septic context 70.8%, emergency surgery 81.1% under the seat me-socolic 25% and 20.3% initial surgical technique. The diagnosis was made preoperatively in 62.2% (n = 92). Ultrasound has found an effusion in 29.7% (n = 44). Cytobactériologic review identified germs in 85.1% (n = 126) and sterile in 12.9% of patients (n = 22). The most frequent etiologies were: 22.9% anastigmatic leak (n = 34), the phoenix abscess in 17.6% (n = 26), iatro-genic perforation 13.5% (n = 20) and digestive fistula 25% (n = 37). Other causes were the stoical necrosis 12.2% (n = 18) and evisceration 8.8% (n = 13). We performed a digestive stoma in 61% (n = 89), a closure of the abdomen bolsters in 8.8% (n = 13), a suture in iatrogenic perforation in 13.5% (n = 20) and washing with drainage in patients with phoenix abscess in 17.6% (n = 26). Morbidity was 22.3% and 53.4% mortality. Conclusion: The diagnosis of post-operative perito-nitis is difficult in a developing country. Morbidity and mortality is high. Improved diagnostic tools are needed.

*Corresponding author.

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Keywords Peritonitis, Postoperative Morbidity and Mortality, Surgery

1. Introduction Postoperative peritonitis poses a diagnostic and treatment challenge to practitioners. They are the most feared complication tank with a mortality ranging from 30% to 71% according to the literature [1]-[4]. This mortality is linked to visceral multi failures it causes. We initiate this study to determine the diagnostic difficulties and pre- and postoperative complications they entail in our country.

2. Patients and Methods It was about a retrospective study of the records of patients operated on between 1999 and 2013 in the general surgery department of the university hospital (CHU) Gabriel Touré. We have included the patients whose age are superior to 15 years whose diagnosis of postoperative peritonitis was made based on clinical, biological, ra-diological and confirmed intraoperatively in all age patients. Non postoperative peritonitis were excluded. The primary endpoint was the highlight of the lesion responsible for postoperative peritonitis (fistula, necrosis, per-foration iatrogenic intra abdominal abscess residual) after laparotomy in all patients. The secondary endpoints were: • The presence of abdominal symptoms (not laxation, abdominal distension, parietal suppuration) and/or ex-

tra-abdominal (fever, septic shock, jaundice) in postoperative period. We made samples of pus for cytology examination to isolate the germ. Imaging (Ultrasound Scanner) and biology were carried out systematically in cases of abdominal distension, clinical signs of perforation or multiorgan failure.

• The prognosis in these patients was assessed using the score Mannheim prognostic index (MPI). For data, we used:

• Registers operative report, the consultation registers and medical records of patients. Entry and data analysis were performed using the epi info software version 7. Testing validity of the results is the Chi-square test with a probability level of p < 0.001 (and in cases where the theoretical size is <5, we used the test of validi-ty of Fisher). The study was conducted with the consent of patients.

3. Results 3.1. Epidemiology In 14 years, we achieved record 23573 lantern and 148 cases of postoperative peritonitis or 0.62%. It was about 80 hommes (54.1%) and 68 women (45.9%). The average age was 37 ± 1 years 17.7 (13 - 80). The outcome of digestive fluid and abdominal pain were the main warning signs respectively 23.6% (35 cases) and 21.6% (32 cas). The delay between the initial intervention and reoperation was less than 5 days. Patients were initially op-erated in emergency in 81.1% of cases.

3.2. Clinic Found Most Were Clinical Signs Fever 27.7% (n = 41), hypotension 37.2% (n = 55), abdominal distension 21.6% (n = 32), the cry of the umbili-cus 66.9% (n = 99), diffuse dullness 22.3% (n = 33) and abdominal contracture 47.3% (n = 70). Other signs are summarized in Table 1. Ultrasonography was performed in 44 patients (29.7%) found an effusion. The review identified cytobacteriologic germs in 85.1% (n = 126) and sterile in 12.9% of patients (n = 22).

3.3. Intraoperative Findings All patients were operated. Intraoperatively, we noted the presence of pus in varying amounts in all patients 100%. The most frequent etiologies were: 22.9% anastomotic leak (n = 34), the phrenic abscess in 17.6% (n = 26), iatrogenic perforation 13.5% (n = 20) and digestive fistula 25% (n = 37). Other causes were the stomiale necrosis 12.2% (n = 18) and evisceration 8.8% (n = 13). Gestures made: we conducted a sample of pus for bac-

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teriological examination and administered broad spectrum antibiotics pending the identification of germs. Di-gestive stoma was performed in 61% (n = 89). Of these, 12.2% had a small bowel necrosis in that necrosis car-rying a resection was performed previously. For patients with evisceration, we proceeded to the closure of the abdomen bolsters 8.8% (n = 13). A suture in iatrogènes13 perforations, 5% (n = 20). Washing with drainage were performed in patients with phrenic abscess in 17.6% (n = 26), but also in other patients 82.4% (n = 122). Surgery: they were single in 24.3% of cases (n = 36) and complicated in 22.3% of patients with type of wound infection 17.6% and 4.7% external digestive fistulas. A sample of the pus was made for cytology examination with susceptibility and local care have helped identify these infections. For digestive fistulas, they have dried in time is an 18 days. Mortality was 53.4% (n = 79) due to septic shock.

4. Discussion The diagnosis of postoperative peritonitis is difficult because of the latent nature of local symptoms which makes the often misleading and non-specific clinical signs. There are no specific laboratory test to reject or con-firm the diagnosis. This atypical clinic is responsible for a delay of reoperation. [5]. Early reoperation before organ failure remains the major concern of the surgeon. After laparotomy, post operative peritonitis is the most common cause 50% - 83% of surgical times [6]. We collected 148casesan incidence 10.5 cases per year and a frequency of 0.6 laparotomy (Table 1). This frequency is close to that reported in the literature [7] while others have found a rate of between 2% to 3.4% [8]-[11]. The average age in our study was 37.1 years close to that re-ported in Ivory Coast [12] but younger than in Europe [13] [14]. Sex is not a risk factor for postoperative perito-nitis occurred while a male predominance has been reported by many authors [13] [15] [16]. The diagnostic de-lay is a derogatory mortality factor of 46.6%, however our postoperative peritonitis were diagnosed during the first postoperative week (less than 5 days) with 31.8% of early diagnosis. Clinical semi logy of postoperative peritonitis is not specific and often recognized late. Digestive signs that we have recorded: 47.3% contracture, the abdominale 23 pain, 6%, 21.6% and distention after digestive fluid 21.6% are reported in the literature [14] [15] to varying frequencies but close to ours. We noted against by a frequency difference in signs extradigestifs with others [14] [17], it is 27.7% of the fever, hypotension, 37.2%, 12.2% tachycardia, vomiting and hiccups 10.1% 8.1%. Biological signs, mostly found in our observation was anemia with a hemoglobin level below 10 g/dl in 55.11% of patients against the leukocytosis for studies in Cote d’Ivoire and England [6] [12]. We believe this is due to initial conditions and diagnostic delay. It is based on imaging diagnosis of postoperative peritonitis is confirmed and the decision of reoperation in urgent need [8]. The injected scanner is the gold standard for ob-jectively digestive walls and collections. But due to its unavailability at any time, its high cost, we asked the ul-trasound that is more accessible to patients. Morphological signs were marked by the presence of effusion on ul-trasound in 29.7% (44/55). We believe that the operator dependence of ultrasound is the explanation. The anti-biotic has been used based on isolated nuclei and their sensitivity (Table 2). Peritonitis by anastigmatic disunion is the most common etiology of postoperative peritonitis [8] [18]. In our study we recorded more than 37 diges-tive fistulas (25%) (Table 3) as anastigmatic leak reported in the literature as the most common [8] [15]. We be-lieve that these errors or technical errors are attributable to the surgeon and co-morbidities related field. The de-terminant of postoperative treatment of peritonitis is the reoperation [1]. Early or late recovery is a prognostic factor [1] [8] that can [19] reported a mortality of 61% among patients carrying an organ failure in cases of early reoperation (<24 hours) against 88% in operating again patients beyond the 24th hour. Surgical procedures per-formed in our series were digestive stoma 61% (n = 89), the closure of the abdomen bolsters in 8.8% (n = 13), a Table 1. Postoperative peritonitis and different authors.

Authors Period of Study Size of Sample Postoperative Peritonitis % p Value

Roehrborn A. Allemagne, [2] 2001 5812 2.0 p < 0.001

Drăghici L. Roumanie, [7] 2012 18,676 0.9 p = 0.1

Hssaida R Maroc, [11] 2000 16 2.1 p < 0.001

Coulibaly B Mali, [10] 2013 724 3.4 p < 0.001

Our Study Mali 2013 23,573 0.6

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Table 2. Other clinical signs found in patients.

Clinical signs Number %

Anemia 82 55.11

Parietale suppuration 25 16.5

Tachycardia 18 12.2

Elevated serum creatinine concentrations 17 11.5

Vomiting 15 10.1

Leucocytosis 14 9.5

Hiccup 12 8.1

Table 3. Bacteria and sensitivity of antibiotic.

Bacteria Number Sensitivity of Antibiotic

E. coli 70/126 Ceftriaxone

Enterocoques 30/126 Amoxicilline + Gentamycine

B. fragilis 16/126 Metronidazole et Clindamycine

S. aureus 10/126 Amoxicilline +Acid Clavulanique

Table 4. Wilting postoperative peritonitis of different authors.

Authors Injury

Roehborn A. Allemagne, 2001 [2] n = 112

Augustin P France, 2010 [14] n = 41

Bader Allemagne 2009 [13] n = 114

Our Study Mali GT, 2013 n = 148

Digestive Fistula - 9 (22.0%) - 37 (25%)

Disunion Anastomosis 44 (66%) 14 (34.0%) 58 (50.9%) 34 (22.9%)

Intra-Abdominal Abscesses 9 (13%) 10 (24%) 3 (5.4%) 26 (17.6%)

Perforation Iatrogenic 7 (10%) 16 (39.0%) 26 (22.8%) 20 (13.5%)

Necrosis Intestinale - - - 18 (12.2%)

Evisceration - - - 13 (8.8%)

suture perforations iatrogènes13.5% (n = 20) washing and drainage in all patients. We recorded a morbidity of 22.3%, with the predominant complication fistula (25%). This result is lower than those of Degremont 50% in France [20] and Gonollu Turkey 32.4% [21]. The overall mortality rate of postoperative intra-abdominal infec-tions is variable. The mortality rate in our study was 53.4%, or more than half of patients (Table 4). This result is higher than Dellinger 29% [3] and Chichom 29.8% [22] but lower than Nel 71% [4]. The causes of death in our series were acute renal failure, hepatic and septic shock.

5. Conclusion Postoperative peritonitis is a serious complication of abdominal surgery, often difficult to diagnose. Support based on a multidisciplinary approach in which the surgeon, anesthetist and intensives radiologist plays a signif-icant role. Only an early and effective therapeutic management can reduce morbidity and mortality in our coun-try.

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